Multimorbidity and co-occurring musculoskeletal pain do not modify the effect of the SELFBACK app on low back pain-related disability

Cecilie K Øverås, Tom I L Nilsen, Barbara I Nicholl, Guy Rughani, Karen Wood, Karen Søgaard, Frances S Mair, Jan Hartvigsen, Cecilie K Øverås, Tom I L Nilsen, Barbara I Nicholl, Guy Rughani, Karen Wood, Karen Søgaard, Frances S Mair, Jan Hartvigsen

Abstract

Background: SELFBACK, an artificial intelligence (AI)-based app delivering evidence-based tailored self-management support to people with low back pain (LBP), has been shown to reduce LBP-related disability when added to usual care. LBP commonly co-occurs with multimorbidity (≥ 2 long-term conditions) or pain at other musculoskeletal sites, so this study explores if these factors modify the effect of the SELFBACK app or influence outcome trajectories over time.

Methods: Secondary analysis of a randomized controlled trial with 9-month follow-up. Primary outcome is as follows: LBP-related disability (Roland Morris Disability Questionnaire, RMDQ). Secondary outcomes are as follows: stress/depression/illness perception/self-efficacy/general health/quality of life/physical activity/global perceived effect. We used linear mixed models for continuous outcomes and logistic generalized estimating equation for binary outcomes. Analyses were stratified to assess effect modification, whereas control (n = 229) and intervention (n = 232) groups were pooled in analyses of outcome trajectories.

Results: Baseline multimorbidity and co-occurring musculoskeletal pain sites did not modify the effect of the SELFBACK app. The effect was somewhat stronger in people with multimorbidity than among those with LBP only (difference in RMDQ due to interaction, - 0.9[95 % CI - 2.5 to 0.6]). Participants with a greater number of long-term conditions and more co-occurring musculoskeletal pain had higher levels of baseline disability (RMDQ 11.3 for ≥ 2 long-term conditions vs 9.5 for LBP only; 11.3 for ≥ 4 musculoskeletal pain sites vs 10.2 for ≤ 1 additional musculoskeletal pain site); along with higher baseline scores for stress/depression/illness perception and poorer pain self-efficacy/general health ratings. In the pooled sample, LBP-related disability improved slightly less over time for people with ≥ 2 long-term conditions additional to LBP compared to no multimorbidity and for those with ≥4 co-occurring musculoskeletal pain sites compared to ≤ 1 additional musculoskeletal pain site (difference in mean change at 9 months = 1.5 and 2.2, respectively). All groups reported little improvement in secondary outcomes over time.

Conclusions: Multimorbidity or co-occurring musculoskeletal pain does not modify the effect of the selfBACK app on LBP-related disability or other secondary outcomes. Although people with these health problems have worse scores both at baseline and 9 months, the AI-based selfBACK app appears to be helpful for those with multimorbidity or co-occurring musculoskeletal pain.

Trial registration: NCT03798288 . Date of registration: 9 January 2019.

Keywords: Artificial intelligence; Comorbidity; Digital technology; Low back pain; Mobile applications; Multimorbidity; Musculoskeletal pain; Randomized controlled trial; Self-management; Telemedicine.

Conflict of interest statement

All authors declare no competing interests.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Flow of participants. LBP, low back pain; LTCs, long-term conditions; MSK, musculoskeletal
Fig. 2
Fig. 2
Distributions of number and types of LTCs and co-occurring MSK pain sites at baseline. LTCs, long-term conditions; MSK, musculoskeletal
Fig. 3
Fig. 3
RMDQ scores and improvement at all time points for participants with and without multimorbidity and co-occurring MSK pain. RMDQ, Roland Morris Disability Questionnaire; MSK, musculoskeletal; LBP, low back pain

References

    1. Hurwitz EL, Randhawa K, Yu H, Côté P, Haldeman S. The Global Spine Care Initiative: a summary of the global burden of low back and neck pain studies. Eur Spine J. 2018;27:796–801. doi: 10.1007/s00586-017-5432-9.
    1. GBD 2019 Diseases and Injuries Collaborators Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396:1204–1222. doi: 10.1016/s0140-6736(20)30925-9.
    1. Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, et al. What low back pain is and why we need to pay attention. Lancet. 2018;391:2356–2367. doi: 10.1016/s0140-6736(18)30480-x.
    1. Øverås CK, Johansson MS, de Campos TF, Ferreira ML, Natvig B, Mork PJ, et al. Distribution and prevalence of musculoskeletal pain co-occurring with persistent low back pain: a systematic review. BMC Musculoskelet Disord. 2021;22:91. doi: 10.1186/s12891-020-03893-z.
    1. Hartvigsen J, Natvig B, Ferreira M. Is it all about a pain in the back? Best Pract Res Clin Rheumatol. 2013;27:613–623. doi: 10.1016/j.berh.2013.09.008.
    1. Coggon D, Ntani G, Walker-Bone K, Palmer KT, Felli VE, Harari R, et al. Epidemiological differences between localized and nonlocalized low back pain. Spine (Phila Pa 1976). 2017(42):740–7. 10.1097/BRS.0000000000001956.
    1. Duffield SJ, Ellis BM, Goodson N, Walker-Bone K, Conaghan PG, Margham T, Loftis T. The contribution of musculoskeletal disorders in multimorbidity: implications for practice and policy. Best Pract Res Clin Rheumatol. 2017;31(2):129–144. doi: 10.1016/j.berh.2017.09.004.
    1. Boyd CM, Fortin M. Future of multimorbidity research: how should understanding of multimorbidity inform health system design? Pub Health Rev. 2010;32:451–474. doi: 10.1007/BF03391611.
    1. Academy of Medical Sciences . Multimorbidity: a priority for global health research. London: Academy of Medical Sciences; 2018.
    1. Palladino R, Tayu Lee J, Ashworth M, Triassi M, Millett C. Associations between multimorbidity, healthcare utilisation and health status: evidence from 16 European countries. Age Ageing. 2016;45:431–435. doi: 10.1093/ageing/afw044.
    1. Jani BD, Hanlon P, Nicholl BI, McQueenie R, Gallacher KI, Lee D, et al. Relationship between multimorbidity, demographic factors and mortality: findings from the UK Biobank cohort. BMC Med. 2019;17:74. doi: 10.1186/s12916-019-1305-x.
    1. Fortin M, Lapointe L, Hudon C, Vanasse A, Ntetu AL, Maltais D. Multimorbidity and quality of life in primary care: a systematic review. Health Qual Life Outcomes. 2004;2:51. doi: 10.1186/1477-7525-2-51.
    1. Hestbaek L, Leboeuf-Yde C, Manniche C. Is low back pain part of a general health pattern or is it a separate and distinctive entity? A critical literature review of comorbidity with low back pain. J Manip Physiol Ther. 2003;26:243–252. doi: 10.1016/s0161-4754(03)00003-4.
    1. Hagen EM, Svensen E, Eriksen HR, Ihlebaek CM, Ursin H. Comorbid subjective health complaints in low back pain. Spine (Phila Pa 1976). 2006(31):1491–5. 10.1097/01.brs.0000219947.71168.08.
    1. Smith MD, Russell A, Hodges PW. Do incontinence, breathing difficulties, and gastrointestinal symptoms increase the risk of future back pain? J Pain. 2009;10:876–886. doi: 10.1016/j.jpain.2009.03.003.
    1. Smith MD, Russell A, Hodges PW. How common is back pain in women with gastrointestinal problems? Clin J Pain. 2008;24:199–203. doi: 10.1097/AJP.0b013e31815d3601.
    1. Gore M, Sadosky A, Stacey BR, Tai KS, Leslie D. The burden of chronic low back pain: clinical comorbidities, treatment patterns, and health care costs in usual care settings. Spine (Phila Pa 1976). 2012(37):E668–77. 10.1097/BRS.0b013e318241e5de.
    1. Baykara RA, Bozgeyik Z, Akgul O, Ozgocmen S. Low back pain in patients with rheumatoid arthritis: clinical characteristics and impact of low back pain on functional ability and health related quality of life. J Back Musculoskelet Rehabil. 2013;26:367–374. doi: 10.3233/bmr-130393.
    1. Bener A, Verjee M, Dafeeah EE, Falah O, Al-Juhaishi T, Schlogl J, et al. Psychological factors: anxiety, depression, and somatization symptoms in low back pain patients. J Pain Res. 2013;6:95–101. doi: 10.2147/jpr.S40740.
    1. Ferreira PH, Beckenkamp P, Maher CG, Hopper JL, Ferreira ML. Nature or nurture in low back pain? Results of a systematic review of studies based on twin samples. Eur J Pain. 2013;17:957–971. doi: 10.1002/j.1532-2149.2012.00277.x.
    1. Panagopoulos J, Hancock MJ, Kongsted A, Hush J, Kent P. Does anterior trunk pain predict a different course of recovery in chronic low back pain? Pain. 2014;155:977–982. doi: 10.1016/j.pain.2014.01.023.
    1. Beeckmans N, Vermeersch A, Lysens R, Van Wambeke P, Goossens N, Thys T, et al. The presence of respiratory disorders in individuals with low back pain: a systematic review. Man Ther. 2016;26:77–86. doi: 10.1016/j.math.2016.07.011.
    1. Fernandez M, Ordoñana JR, Hartvigsen J, Ferreira ML, Refshauge KM, Sánchez-Romera JF, et al. Is chronic low back pain associated with the prevalence of coronary heart disease when genetic susceptibility is considered? A co-twin control study of Spanish twins. PLoS One. 2016;11:e0155194. doi: 10.1371/journal.pone.0155194.
    1. Badley EM, Millstone DB, Perruccio AV. Back pain and co-occurring conditions: findings from a nationally representative sample. Spine (Phila Pa 1976). 2018(43):E935–e41. 10.1097/brs.0000000000002590.
    1. Jimenez-Garcia R, Del Barrio JL, Hernandez-Barrera V, de Miguel-Díez J, Jimenez-Trujillo I, Martinez-Huedo MA, et al. Is there an association between diabetes and neck pain and lower back pain? Results of a population-based study. J Pain Res. 2018;11:1005–1015. doi: 10.2147/jpr.S158877.
    1. Violan C, Foguet-Boreu Q, Flores-Mateo G, Salisbury C, Blom J, Freitag M, et al. Prevalence, determinants, and patterns of multimorbidity in primary care: a systematic review of observational studies. PLoS One. 2014;9:e102149. doi: 10.1371/journal.pone.0102149.
    1. Cassell A, Edwards D, Harshfield A, Rhodes K, Brimicombe J, Payne R, et al. The epidemiology of multimorbidity in primary care: a retrospective cohort study. Br J Gen Pract. 2018;68:e245–ee51. doi: 10.3399/bjgp18X695465.
    1. van der Zee-Neuen A, Putrik P, Ramiro S, Keszei A, de Bie R, Chorus A, et al. Impact of chronic diseases and multimorbidity on health and health care costs: the additional role of musculoskeletal disorders. Arthritis Care Res (Hoboken) 2016;68:1823–1831. doi: 10.1002/acr.22913.
    1. Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018;391:2368–2383. doi: 10.1016/s0140-6736(18)30489-6.
    1. Almeida M, Saragiotto B, Richards B, Maher CG. Primary care management of non-specific low back pain: key messages from recent clinical guidelines. Med J Aust. 2018;208:272–275. doi: 10.5694/mja17.01152.
    1. Dennison L, Morrison L, Conway G, Yardley L. Opportunities and challenges for smartphone applications in supporting health behavior change: qualitative study. J Med Internet Res. 2013;15:e86. doi: 10.2196/jmir.2583.
    1. Zhao J, Freeman B, Li M. Can mobile phone apps influence people’s health behavior change? An Evidence Review. J Med Internet Res. 2016;18:e287. doi: 10.2196/jmir.5692.
    1. Aitken MCB, Nass D. The growing value of digital health - evidence and impact on human health and the healthcare system. USA: IQVIA Institute for Human Data Science; 2017.
    1. Nicholl BI, Sandal LF, Stochkendahl MJ, McCallum M, Suresh N, Vasseljen O, et al. Digital support interventions for the self-management of low back pain: a systematic review. J Med Internet Res. 2017;19:e179. doi: 10.2196/jmir.7290.
    1. Mork PJ, Bach K. A decision support system to enhance self-management of low back pain: protocol for the selfBACK project. JMIR Res Protoc. 2018;7:e167. doi: 10.2196/resprot.9379.
    1. Sandal LF, Stochkendahl MJ, Svendsen MJ, Wood K, Øverås CK, Nordstoga AL, et al. An app-delivered self-management program for people with low back pain: protocol for the selfBACK randomized controlled trial. JMIR Res Protoc. 2019;8:e14720. doi: 10.2196/14720.
    1. Sandal LF, Bach K, Øverås CK, Svendsen MJ, Dalager T, Stejnicher Drongstrup Jensen J, et al. Effectiveness of app-delivered, tailored self-management support for adults with lower back pain-related disability: a selfBACK randomized clinical trial. JAMA Intern Med. 2021. 10.1001/jamainternmed.2021.4097.
    1. Kenning C, Fisher L, Bee P, Bower P, Coventry P. Primary care practitioner and patient understanding of the concepts of multimorbidity and self-management: a qualitative study. SAGE Open Med. 2013;1:2050312113510001. doi: 10.1177/2050312113510001.
    1. Gleadhill C, Kamper SJ, Lee H, Williams CM. Exploring integrated care for musculoskeletal and chronic health conditions. J Orthop Sports Phys Ther. 2021;51:264–268. doi: 10.2519/jospt.2021.10428.
    1. Krokstad S, Langhammer A, Hveem K, Holmen TL, Midthjell K, Stene TR, et al. Cohort profile: the HUNT study, Norway. Int J Epidemiol. 2013;42:968–977. doi: 10.1093/ije/dys095.
    1. Kuorinka I, Jonsson B, Kilbom A, Vinterberg H, Biering-Sørensen F, Andersson G, et al. Standardised Nordic questionnaires for the analysis of musculoskeletal symptoms. Appl Ergon. 1987;18:233–237. doi: 10.1016/0003-6870(87)90010-x.
    1. Roland M, Fairbank J. The Roland-Morris Disability Questionnaire and the Oswestry Disability Questionnaire. Spine (Phila Pa 1976). 2000(25):3115–24. 10.1097/00007632-200012150-00006.
    1. Smith SM, Wallace E, Salisbury C, Sasseville M, Bayliss E, Fortin M. A core outcome set for multimorbidity research (COSmm) Ann Fam Med. 2018;16:132–138. doi: 10.1370/afm.2178.
    1. van Hout B, Janssen MF, Feng YS, Kohlmann T, Busschbach J, Golicki D, et al. Interim scoring for the EQ-5D-5L: mapping the EQ-5D-5L to EQ-5D-3L value sets. Value Health. 2012;15:708–715. doi: 10.1016/j.jval.2012.02.008.
    1. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24:385–396. doi: 10.2307/2136404.
    1. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606–613. doi: 10.1046/j.1525-1497.2001.016009606.x.
    1. Brooks R. EuroQol: the current state of play. Health Policy. 1996;37:53–72. doi: 10.1016/0168-8510(96)00822-6.
    1. Hallegraeff JM, van der Schans CP, Krijnen WP, de Greef MH. Measurement of acute nonspecific low back pain perception in primary care physical therapy: reliability and validity of the brief illness perception questionnaire. BMC Musculoskelet Disord. 2013;14:53. doi: 10.1186/1471-2474-14-53.
    1. Nicholas MK. The pain self-efficacy questionnaire: taking pain into account. Eur J Pain. 2007;11:153–163. doi: 10.1016/j.ejpain.2005.12.008.
    1. Grimby G, Börjesson M, Jonsdottir IH, Schnohr P, Thelle DS, Saltin B. The “Saltin-Grimby Physical Activity Level Scale” and its application to health research. Scand J Med Sci Sports 2015;25 Suppl 4:119-125. 10.1111/sms.12611.
    1. Kamper SJ, Maher CG, Mackay G. Global rating of change scales: a review of strengths and weaknesses and considerations for design. J Man Manip Ther. 2009;17:163–170. doi: 10.1179/jmt.2009.17.3.163.
    1. Du S, Liu W, Cai S, Hu Y, Dong J. The efficacy of e-health in the self-management of chronic low back pain: a meta-analysis. Int J Nurs Stud. 2020;106:103507. doi: 10.1016/j.ijnurstu.2019.103507.
    1. Mair FS, May CR. Thinking about the burden of treatment. Bmj. 2014;349:g6680. doi: 10.1136/bmj.g6680.
    1. Mangin D, Parascandalo J, Khudoyarova O, Agarwal G, Bismah V, Orr S. Multimorbidity, eHealth and implications for equity: a cross-sectional survey of patient perspectives on eHealth. BMJ Open. 2019;9:e023731. doi: 10.1136/bmjopen-2018-023731.
    1. Olander EK, Fletcher H, Williams S, Atkinson L, Turner A, French DP. What are the most effective techniques in changing obese individuals' physical activity self-efficacy and behaviour: a systematic review and meta-analysis. Int J Behav Nutr Phys Act. 2013;10:29. doi: 10.1186/1479-5868-10-29.
    1. Samdal GB, Eide GE, Barth T, Williams G, Meland E. Effective behaviour change techniques for physical activity and healthy eating in overweight and obese adults; systematic review and meta-regression analyses. Int J Behav Nutr Phys Act. 2017;14:42. doi: 10.1186/s12966-017-0494-y.
    1. Schroé H, Van Dyck D, De Paepe A, Poppe L, Loh WW, Verloigne M, et al. Which behaviour change techniques are effective to promote physical activity and reduce sedentary behaviour in adults: a factorial randomized trial of an e- and m-health intervention. Int J Behav Nutr Phys Act. 2020;17:127. doi: 10.1186/s12966-020-01001-x.
    1. Svendsen MJ, Wood KW, Kyle J, Cooper K, Rasmussen CDN, Sandal LF, et al. Barriers and facilitators to patient uptake and utilisation of digital interventions for the self-management of low back pain: a systematic review of qualitative studies. BMJ Open. 2020;10:e038800. doi: 10.1136/bmjopen-2020-038800.
    1. Calderón-Larrañaga A, Vetrano DL, Ferrucci L, Mercer SW, Marengoni A, Onder G, et al. Multimorbidity and functional impairment-bidirectional interplay, synergistic effects and common pathways. J Intern Med. 2019;285:255–271. doi: 10.1111/joim.12843.
    1. Ryan A, Wallace E, O'Hara P, Smith SM. Multimorbidity and functional decline in community-dwelling adults: a systematic review. Health Qual Life Outcomes. 2015;13:168. doi: 10.1186/s12955-015-0355-9.
    1. Read JR, Sharpe L, Modini M, Dear BF. Multimorbidity and depression: a systematic review and meta-analysis. J Affect Disord. 2017;221:36–46. doi: 10.1016/j.jad.2017.06.009.
    1. Zemedikun DT, Gray LJ, Khunti K, Davies MJ, Dhalwani NN. Patterns of multimorbidity in middle-aged and older adults: an analysis of the UK biobank data. Mayo Clin Proc. 2018;93:857–866. doi: 10.1016/j.mayocp.2018.02.012.
    1. Heikkinen J, Honkanen R, Williams L, Leung J, Rauma P, Quirk S, et al. Depressive disorders, anxiety disorders and subjective mental health in common musculoskeletal diseases: a review. Maturitas. 2019;127:18–25. doi: 10.1016/j.maturitas.2019.05.011.
    1. Bayattork M, Jakobsen MD, Sundstrup E, Seidi F, Bay H, Andersen LL. Musculoskeletal pain in multiple body sites and work ability in the general working population: cross-sectional study among 10,000 wage earners. Scand J Pain. 2019;19:131–137. doi: 10.1515/sjpain-2018-0304.
    1. Sundstrup E, Jakobsen MD, Mortensen OS, Andersen LL. Joint association of multimorbidity and work ability with risk of long-term sickness absence: a prospective cohort study with register follow-up. Scand J Work Environ Health. 2017;43:146–154. doi: 10.5271/sjweh.3620.
    1. Andersén H, Kankaanranta H, Tuomisto LE, Piirilä P, Sovijärvi A, Langhammer A, et al. Multimorbidity in Finnish and Swedish speaking Finns; association with daily habits and socioeconomic status - Nordic EpiLung cross-sectional study. Prev Med Rep. 2021;22:101338. doi: 10.1016/j.pmedr.2021.101338.
    1. Wertli MM, Held U, Campello M, Schecter WS. Obesity is associated with more disability at presentation and after treatment in low back pain but not in neck pain: findings from the OIOC registry. BMC Musculoskelet Disord. 2016;17:140. doi: 10.1186/s12891-016-0992-0.
    1. Vinjerui KH, Boeckxstaens P, Douglas KA, Sund ER. Prevalence of multimorbidity with frailty and associations with socioeconomic position in an adult population: findings from the cross-sectional HUNT Study in Norway. BMJ Open. 2020;10:e035070. doi: 10.1136/bmjopen-2019-035070.
    1. Pathirana TI, Jackson CA. Socioeconomic status and multimorbidity: a systematic review and meta-analysis. Aust N Z J Public Health. 2018;42:186–194. doi: 10.1111/1753-6405.12762.
    1. Hanlon P, Hannigan L, Rodriguez-Perez J, Fischbacher C, Welton NJ, Dias S, et al. Representation of people with comorbidity and multimorbidity in clinical trials of novel drug therapies: an individual-level participant data analysis. BMC Med. 2019;17:201. doi: 10.1186/s12916-019-1427-1.
    1. Smith SM, Soubhi H, Fortin M, Hudon C, O'Dowd T. Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. Bmj. 2012;345:e5205. doi: 10.1136/bmj.e5205.
    1. Schäfer I, Kaduszkiewicz H, Wagner HO, Schön G, Scherer M, van den Bussche H. Reducing complexity: a visualisation of multimorbidity by combining disease clusters and triads. BMC Public Health. 2014;14:1285. doi: 10.1186/1471-2458-14-1285.
    1. Kongsted A, Hestbaek L, Kent P. How can latent trajectories of back pain be translated into defined subgroups? BMC Musculoskelet Disord. 2017;18:285. doi: 10.1186/s12891-017-1644-8.
    1. da Silva T, Mills K, Kongsted A, Maher CG, Hancock M. What is the personal impact of recurrences of low back pain? Subanalysis of an Inception Cohort Study. J Orthop Sports Phys Ther. 2020;50:294–300. doi: 10.2519/jospt.2020.9345.
    1. Smith SM, Wallace E, O'Dowd T, Fortin M. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst Rev. 2021;1:Cd006560. doi: 10.1002/14651858.CD006560.pub4.
    1. Sakib MN, Shooshtari S, St John P, Menec V. The prevalence of multimorbidity and associations with lifestyle factors among middle-aged Canadians: an analysis of Canadian Longitudinal Study on Aging data. BMC Public Health. 2019;19:243. doi: 10.1186/s12889-019-6567-x.
    1. Møller SP, Laursen B, Johannesen CK, Tolstrup JS, Schramm S. Patterns of multimorbidity and demographic profile of latent classes in a Danish population-A register-based study. PLoS One. 2020;15:e0237375. doi: 10.1371/journal.pone.0237375.
    1. Hanlon P, Nicholl BI, Jani BD, Lee D, McQueenie R, Mair FS. Frailty and pre-frailty in middle-aged and older adults and its association with multimorbidity and mortality: a prospective analysis of 493 737 UK Biobank participants. Lancet Public Health. 2018;3:e323–ee32. doi: 10.1016/s2468-2667(18)30091-4.
    1. Petermann-Rocha F, Hanlon P, Gray SR, Welsh P, Gill JMR, Foster H, et al. Comparison of two different frailty measurements and risk of hospitalisation or death from COVID-19: findings from UK Biobank. BMC Med. 2020;18:355. doi: 10.1186/s12916-020-01822-4.
    1. Rasmussen CDN, Svendsen MJ, Wood K, Nicholl BI, Mair FS, Sandal LF, et al. App-delivered self-management intervention trial selfBACK for people with low back pain: protocol for implementation and process evaluation. JMIR Res Protoc. 2020;9:e20308. doi: 10.2196/20308.

Source: PubMed

Patrocinadores e Colaboradores

Condições médicas

Intervenções de drogas

3
Se inscrever